Who Does Your Doctor Really Work For?

Early March was not a good time to break a bone. You might have had a
difficult time finding someone to fix it, since thousands of orthopedists were
otherwise occupied in San Francisco, at the 75th annual meeting of the
American Academy of Orthopaedic Surgeons (AAOS).

The mood there wasn't entirely jubilant. The past year has been a tough one for
the business of orthopedics, one in which it has taken a hard, public slap
from the U.S. Department of Justice (DOJ).

The DOJ, you see, has discovered the "relationships" that so many orthopedic
companies have established with orthopedic surgeons. Companies give money to
doctors to test products, to help design or tout products and sometimes just
to use a particular product (as in kickback). Orthopedists are hardly the
only doctors paid by medical companies, but when the sheer amount of money
being given to orthopedists came out of the shade into the sharp San
Francisco sunshine last week, it did make quite a few of us blink.

The DOJ's slap was felt acutely by everyone at the convention. No more free
dinners, shoulder bags, flashlights and pens. Way fewer models in leotards
draped across operating tables and traction equipment. A new ruling requires
every research presentation to begin with full disclosure of all monetary
relationships the speaker has with any company. Every single fully trained
doctor I heard speak was getting paid by a company; many of the bigger-name
doctors were getting paid by three or four. How much money was still the
subject of gossip  the exact amount is not required to be broadcast in
these podium confessionals. The DOJ has, however, ordered companies to list
the doctors in their employ, as well as the amounts paid them, on their
websites. Judging by those figures, it adds up to plenty. And it
got our attention at AAOS. Some doctors thought it immoral; others lamented
the doubt it cast on the integrity of research. But I think most just
wanted in.

If there's one thing that a life spent mending broken bodies makes you, it's
realistic. Most surgeons are quite realistic about capitalism. We see its
very essence, the power of monetary incentive, over nearly everyone in our
world. We see it in the extra lab tests that please patients as well as pay
(and protect) doctors, in the fleet of blank-faced bureaucrats floating to
their next paychecks on rivers of inane hospital regulations, and in the TV
drug ads for restless legs, erectile errors and feminine itches. We know
what they're after.

Not that these shenanigans are completely new to us. When you spend your
life outfitting patients with the Joe Dokes Knee Prosthesis, you get a
glimmer that Joe Dokes himself must be making some money on the thing. But
there are 17,000 orthopedists in the U.S., and with this convention a large
fraction of us came to the simultaneous realization that just about all of
our teachers and mentors  the surgeons we hold in high regard, who do
the important research, who work in the teaching programs, who write the
papers and give us these lectures  are "consultants."

Maybe it's part of growing up as a doctor  to put away childish notions
like "pure academics." Or, perhaps, we should be reassured by the peer-review
process, which all the papers must undergo: papers get chosen for
publication only after impartial, third-party doctors have read and vetted
them. The vast majority of the time this is pretty good proof that
researchers aren't just company shills. But that mandatory confessional is
still required in print, stark like the warning on a pack of cigarettes: "This guy
is taking money from a company so take what he says with a grain of salt."

It's not just uncertainty about the legitimacy of the new research that
rankles. It's also the fact that most of our research is probably
legitimate, but unfortunately real doubt is being cast on the basic truths
and actual progress of our practice. The ultimate cost of this will likely
be borne by our patients. Take the small-town surgeon, who goes to the
convention in San Francisco and hears the financial disclaimers. Like many
others, his own practice at home is floundering financially. Between his
natural envy of the corporate money and the doubt it casts on what he's
supposed to be learning, he goes home disillusioned and probably less well
educated  and with so few orthopedists in so many small towns, his
patients lose out too.

Orthopedists know about fixing bones, but there is no operation to fix
fractured trust. We take medical lies personally. They are, like all lies,
offensive, even poisonous, to something deep within. It's surely not a
physical poison; while our brains can be hurt by chemicals, our minds are
only made of (true) ideas. Lies (untrue ideas) can rot the substance of a
mind. Insofar as human life is different from the life of a mindless
thing, like a tree, lies  even little lies about new pills and braces
 are things that kill us. That's why they're so offensive.

An administrative judge, facing a moral dilemma of greater than medical
proportions, once asked his defendant, "What is truth?" The famous silence
of that defendant's reply might have been an answer, an eloquent one in
fact. Truth standing right there, knowable, yet, as then by Pilate, it
was, for reasons of expediency, or money, ignored. Yet the truth did
win out. It's a lot like this in surgery now. Our consultants might have
conflicts, but sooner or later they will have to come back to us; if you really
are a doctor, the truth is where the fun is. That's why I know they'll get
around, eventually, to teaching us what we need.